Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �p APPLICATION <br /> I (For Non-Transferable, Revocable, and-Su spendable) <br /> I� ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appiicatio h reby mg4e to c ry on bu ' ess in the jurisdictional area of the San Joaquin Lo(,gHealt i i <br /> HBusiness N e (DB Address I <br /> t <br /> aOwner I'. Address <br /> Firm Partners, Addresses and Tele niNumbers <br /> aBusiness Telephone No. J Emergency Telephone Na. "p <br /> Contractor Licence No. n4L <br /> E <br /> L Applicants Name (Print) Title r Date <br /> Please check Applicable Category (1 07) and Fill in the Required Information q <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,_ Juhle 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. i CAL. License No. CAL. Licznse Renewal No. } <br /> Capacity_ Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 it <br /> No. of Vehicles Stored 0 <br /> l <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ' <br /> n <br /> R.S. or R.G.E. Name =J! R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. KSANITATION PERMIT �L <br /> Job Address/Loc r <br /> Owner Address <br /> ❑ SEPTIC TAZO7 ❑ CESSPOOL ❑ LEACHING FIELD XSEEPAGE PIT PACKAGE PLANT <br /> FPERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 11 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units II Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name II Where Certified <br /> Plant Location <br /> Plant Capacity II No. Units Served i <br /> 7. ❑ LAUNDRY For July 1, -Junel30, 19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,11 ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a 'ns regulations of a San-Jovu. Local Health District. <br /> APPLICANT'S SIGNATURE X li <br /> II - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY: ❑ PER UNIT PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMET <br /> II BILLING REMITTANCE $ r AMOUNT DUE D <br /> BASE EXPLANATION <br /> - EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 1 n <br /> PRORATIONCJ <br /> PLUS <br /> PENALTY I1 <br /> OTHER l �� <br /> 4 <br /> OTHER <br /> Received by -Date Receipt No. Permit No. Issuan ate Mailed -Deli <br /> Vt <br /> De ive <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.,HAZELTON AVE.,P.O.Box 2004 STOCK N,CA 35 01 <br /> . ^ 1 <br />